What is the recommended treatment for lichen planus?

Treatment of Lichen Planus

High-potency topical corticosteroids are the first-line treatment for all forms of lichen planus, including cutaneous, oral, and genital lesions. 1

Treatment Based on Location and Type

Cutaneous Lichen Planus

• Apply high-potency topical corticosteroids (such as clobetasol propionate 0.05%) twice daily to affected areas for 2-3 months, followed by gradual tapering to prevent rebound flares 1, 2
• For moderate to severe or widespread disease, consider adding:
  • Oral antihistamines for pruritus control 1
  • Narrow-band UVB phototherapy 1
  • A short course of systemic corticosteroids 1, 2
• For refractory cases, consider:
  • Intralesional triamcinolone acetonide injections 1
  • Referral to dermatology for systemic immunomodulators 1, 3

Oral Lichen Planus

• Apply clobetasol propionate 0.05% or fluocinonide 0.05% gel to dried mucosa twice daily for 2-3 months, then taper gradually 1, 4
• Use gel formulations rather than creams/ointments for better adherence to mucosal surfaces 1, 4
• For localized lesions, clobetasol 0.05% can be mixed in 50% Orabase and applied twice weekly 1
• Topical calcineurin inhibitors (tacrolimus 0.1% ointment) are effective alternatives when corticosteroids are contraindicated or ineffective 1, 4
• Regular follow-up is necessary to monitor for potential malignant transformation, especially in erosive forms 2, 5

Genital Lichen Planus

• High-potency topical corticosteroids are first-line therapy 1, 2
• Topical tacrolimus appears to be an effective treatment for vulvovaginal lichen planus 2
• For lichen sclerosus, clobetasol propionate 0.05% twice daily for 2-3 months with gradual tapering is recommended 1
• In males with genital lichen sclerosus limited to the foreskin and glans, circumcision may be beneficial 1

Nail Lichen Planus

• Intralesional and intramuscular triamcinolone acetonide should be considered first-line therapies rather than topical treatments 6
• Oral retinoids are second-line choices for nail involvement 6
• Early treatment is essential to prevent permanent nail destruction 6

Treatment for Refractory Disease

• Systemic corticosteroids should be considered for severe, widespread lichen planus involving multiple sites 2
• Alternative systemic treatments include:
  • Acitretin (30 mg daily for 8 weeks) 7
  • Doxycycline with nicotinamide 1
  • Other immunosuppressants such as methotrexate, hydroxychloroquine, cyclosporine, azathioprine, or mycophenolate mofetil for challenging cases 3

Important Clinical Considerations

• Biopsy is necessary to confirm diagnosis in atypical cases and to rule out malignancy 1
• Lichen planus may resolve spontaneously within 1-2 years, but recurrences are common 2
• Mucosal forms tend to be more persistent and resistant to treatment than cutaneous forms 2
• Advise patients to avoid irritants and fragranced products that may exacerbate the condition 1
• Regular follow-up at 3 months is necessary to assess treatment response 1, 8
• Potential side effects of topical steroids include cutaneous atrophy, adrenal suppression, hypopigmentation, and contact sensitivity 8

Special Considerations

• Investigate potential underlying causes such as medications (gold, antimalarials, penicillamine, thiazide diuretics, beta blockers, NSAIDs, quinidine, ACE inhibitors) or hepatitis C virus infection 5
• Surgical management may be needed for cases with anatomical changes or strictures 1
• Psychosexual issues should be addressed when genital disease affects quality of life 9